<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201437
Report Date: 01/04/2023
Date Signed: 01/24/2023 12:51:20 PM

Document Has Been Signed on 01/24/2023 12:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIAZ CARE HOME IIFACILITY NUMBER:
547201437
ADMINISTRATOR:ANTONIO DIAZFACILITY TYPE:
735
ADDRESS:2128 SOUTH ASHTON COURTTELEPHONE:
(559) 738-1008
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Vanessa Garduno. TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/24/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and was allowed entry by administrator Vanessa Garduno.

Facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. LPA checked PPE supplies and residents’ locked medications and observed a 30-day supply. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed fire extinguisher served date: 12/5/2022.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 3 bedrooms shared resident’s bedroom to be at least 6 feet apart. LPA toured bathrooms and observed Trash bins with lids and hand washing signs. Cleaning supplies were stored and locked in laundry room The exterior tour was conducted. Side gate was self-closing and self-latching. Last fire drill was conducted on 01/1/2023. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.



No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/31/2023: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with administrator. Report signed on-site; printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1